Arterial Interventions and Peripheral Arterial Disease (PAD)

Session: Educational Exhibit Presentations - Station 1: Arterial Interventions and Peripheral Arterial Disease (PAD)

Percutaneous Distal Deep Venous Arterialization (dDVA): A Case-Based Review of Clinical Indications and Interventional Techniques

Monday, March 6, 2023

5:35 PM – 5:40 PM

Location: Phoenix Convention Center, North Ballroom 120ABC, Poster Hall

Abstract Presenter(s)

Tony Tae Kyung Kim, MD

Resident Physician
Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital

Disclosure(s): No financial relationships to disclose

Author/Co-author(s)

Sabeen Dhand, MD

Interventional Radiologist
LAIIC, PIH Health
KM

Kumar Madassery, MD

Associate Professor, Vascular and Interventional Radiology
Rush University Medical Center, Rush Oak Park
BH

Brian Holly, MD

Program Director
Johns Hopkins Hospital
ML

Mark L. Lessne, MD

Vascular and Interventional Radiologist
Vascular & Interventional Specialists, Charlotte Radiology

Disclosure(s):

Tony Tae Kyung Kim, MD: No financial relationships to disclose

Sabeen Dhand, MD: Backtable: Host (Ongoing), Ownership Interest (Ongoing); viz.ai: Consultant (Ongoing)

Kumar Madassery, MD: Abbott Vascular: Consultant (Ongoing); Cook Mediical: Consultant (Ongoing); Koninklijke Philips: Consultant (Ongoing); PENUMBRA INC: Consultant (Ongoing)

Mark L. Lessne, MD: ABBOTT, ANGIODYNAMICS, ANGIOSAFE, BD BARD, BOSTON SCIENTIFIC, CSI – FRONTIER, INTACT VASCULAR, ABBOTT, MEDTRONIC, MICRO MEDICAL SOLUTIONS, PLURISTEM, LTD SURMODICS, VERYAN, VESPER MEDICAL: Consultant (Ongoing), Speaking and Teaching (Ongoing); Baylis Medical Technologies: Speaking and Teaching (Ongoing); CARDIOVASCUAR SYSTEMS (CSI), CORDIS/CARDINAL HEALTH, INARI MEDICAL INC., INTACT VASCULAR, MEDTRONIC, PHILIPS, VESPER: Consultant (Ongoing); Merit Medical: Contracted Research (Ongoing); phillips/volcano/Spectranetics: Speaking and Teaching (Ongoing); Terumo: Speaking and Teaching (Ongoing)

Learning Objectives:

To describe percutaneous distal deep venous arterialization (dDVA) via a case-based discussion, including patient selection, technical tips, post-procedural management, and clinical follow-up.

To highlight advantages and technical differences of distal deep venous arterialization compared to the more conventional proximal deep venous arterialization (pDVA).

Background:

Chronic limb-threatening ischemia (CLTI) is the most severe complication of peripheral artery disease (PAD), which affects ~ 8.5 million Americans{1}. Patients with “no-option” CLTI, including those without patent arteries in the foot (“desert foot” or “small vessel disease”), do not benefit from surgical bypasses and may fail even the most complex endovascular arterial procedures. pDVA, in which an arteriovenous fistula is created percutaneously between the proximal tibial artery and vein, usually with stent grafts placed along the length of the vein to the ankle, has increasingly been used to offer an additional limb salvage option to these patients. pDVA can be associated with severe side effects, known as DVA storm. A newer variation of the DVA technique, dDVA, has potential advantages to reduce venous hypertension, obviate the need for stent grafts to lower cost, and diminish deleterious side effects.

Clinical Findings/Procedure Details:

Percutaneous dDVA involves percutaneous creation of a fistula between a distal tibial artery and distal tibial vein, usually just above the ankle joint, in conjunction with disruption of venous valves in the foot. Stent scaffolding is used only at the fistula site or avoided altogether. This exhibit will highlight real-world clinical scenarios, including discussion of indications, complications, intraprocedural tips, and post-procedural management of the dDVA procedure. Various procedural techniques including catheter selection, techniques of fistula creation with commercial devices or gunsight technique will be described with follow-up clinical images.

Conclusion and/or Teaching Points:

Percutaneous dDVA provides patients with “no-option” CLTI an opportunity for wound healing and limb salvage with potential advantages compared to pDVA. As interventional radiologists are increasingly caring for patients with CLTI, they must be familiar with patient selection and procedure planning for dDVA to be successful and effective.